Subclinical Primary Aldosteronism and Cardiovascular Health

Quick Takes

  • Subclinical primary aldosterone is likely under-recognized and can lead to negative CV consequences.
  • Patients with subclinical primary aldosteronism can have negative CV consequences independent of BP.
  • Subclinical primary aldosteronism may be a future target of treatment in CV primary prevention.

Study Questions:

Does mild or subclinical renin-independent (“primary”) aldosteronism increase the chance of cardiovascular (CV) disease?


A total of 1,284 subjects between the ages of 40 and 69 years were selected in a population-based fashion in the CARTaGENE cohort in Québec, Canada. CARTaGENE is an ongoing cohort of 40,000 people in Québec. Renin and aldosterone were measured, and aldosterone-to-renin ratios were calculated, identifying subjects with renin-independent aldosteronism. CV health was assessed using magnetic resonance imaging (MRI), incident hypertension, and arterial stiffness.


Subjects identified with subclinical or mild primary aldosteronism were found to have worse overall CV health. This was evidenced by increased arterial wall stiffness as assessed by central blood pressure (BP) and pulse wave velocity. They also had adverse cardiac remodeling as assessed by MRI that included several parameters including left ventricular (LV) mass index, LV remodeling index, left atrial volume, and LV hypertrophy. Finally, they had a higher incidence of hypertension. These findings were independent of baseline brachial BP.


Subclinical and mild primary aldosteronism is associated with worsened overall CV health as defined by increased arterial stiffness, cardiac remodeling as assessed by MRI, and the development and presence of hypertension.


The tremendous success in targeted pharmacologic therapy for hypertension may have blunted our overall enthusiasm in pursuing the mechanisms of the overall causes of hypertension. After all, we have therapies for this common ailment that are proven to decrease overall CV risk, so is it really necessary to know exactly why hypertension happens?

This article by Hundemer et al. is an important reminder that mechanism is important. Subclinical and mild aldosteronism indeed is associated with elevated BP. But even when it is not associated with hypertension, there are CV consequences. Perhaps these consequences are already in play years before patients develop hypertension and that the high BP then only worsens the situation.

In 2006, the TROPHY (Trial of Prevention of Hypertension) group led by Dr. Stevo Julius suggested that treatment of pre-hypertensive patients with an angiotensin receptor blocking agent decreased the percentage of subjects with hypertension years after the pre-treatment was stopped. This was likely attributable to the slowing of vascular remodeling that was already occurring even in the normotensive patients. Similarly, small elevations in plasma aldosterone, as in this study, may be doing their CV harm long before a patient becomes frankly hypertensive.

This study is important in that it should alert us to keep vigilant for mild, subclinical aldosteronism as a potential treatment target. There are therapies in development such as baxdrostat that inhibit aldosterone production and may potentially improve the outcomes in these patients. Naturally, more clinical trials are needed to make that link. Moreover, it should remind us that once a patient develops high BP numbers, a lot of damage may have already occurred. The future treatment of hypertension may go beyond just getting presently high numbers down and include looking at other markers of CV risk in an effort to slow CV damage before frank hypertension develops.

Clinical Topics: Prevention

Keywords: Aldosterone, Blood Pressure

< Back to Listings